Nurse staffing in neonatal intensive care


Poets CF, Helder O, Tissières P, Mader S, Härtel C, Rossi R

© Christian Klant Photography

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

Nurse staffing levels reflect the needs of the infants they are caring for, which include one to one nursing during intensive care and one to two nursing during intermediate care.


At present, nurse staffing levels vary widely between neonatal services. (1,2) There is evidence that insufficient nursing numbers are associated with increased mortality and increased infection rates. (3–9) Data indicate that provision of sufficient nursing staff will facilitate the timely delivery of neonatal care (3), allow for better prevention of nosocomial infections (10–12), result in better compliance with set oxygen saturation targets5, and improved hand hygiene compliance. (13) There is also a relationship between the proportion of one to one nursing achieved and mortality. (14)

Evidence-based standards in this area include:

  • an agreed proportion of nurses working in the NICU should have ≥3 years work experience in a NICU or completed post-registration education in intensive care (15,16)
  • a nurse-to-infant ratio of one to one (15,16) (one nurse for one infant) for infants requiring intensive care, of one to two (15,16) (one nurse for two infants) for infants needing intermediate care, and a ratio of at least one to four for all infants requiring special care (15)
  • in addition to nursing staff, support should be available from professionals with specific expertise in neonatal practice in the following areas: social work, psychology dietetics, physiotherapy, speech and language therapy, pharmacy, as well as nursing aids (15–20) (see TEG Infant-and family-centred developmental care)


Short-term benefits

  • Timely delivery of neonatal care (3)
  • Reduced risk of nosocomial infections (10–12)
  • Improved compliance with set oxygen saturation targets in infants (5)
  • Improved hand hygiene compliance (13)
  • Reduced neonatal mortality (8)

Long-term benefits

  • Improved long-term outcomes (6)


Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are supported to be the primary caregiver. B (High quality) Parent feedback
For healthcare professionals    
2. Patient’s care has priority over administrative and housekeeping tasks for nurses in clinical care. B (High quality) Guideline
For neonatal unit    
3. A unit guideline on nurse staffing requirements is available and regularly updated. B (High quality) Guideline
4. Sufficient nurse staffing numbers to provide appropriate levels of neonatal care is ensured: (15,16) A (High quality)
C (Moderate quality)
Audit report
  • One nurse to one patient for intensive care (14)
  • One nurse to two patients for intermediate care
  • One nurse to four patients during special care
  • In addition, one nurse to provide shift coordination
For hospital    
5. Sufficient nurse staffing numbers for care and continuing professional development and education of staff is ensured. (15,16) (see TEG Education & training) A (Moderate quality) Audit report, training documentation
For health service    
6. A national guideline on nurse staffing requirements is available and regularly updated. B (High quality) Guideline
7. The staffing required by a unit is defined according to the number of beds and the care level of the beds. (15,16) A (Moderate quality)
C (Moderate quality)
Audit report
8. Adequate national or regional training places on accredited educational courses are ensured. (see TEG Education & training) A (Moderate quality)
B (High quality
Audit report

Where to go

Further development Grading of evidence
For parents and family  
For healthcare professionals  
For neonatal unit  
For hospital and health service  
  • Develop initiatives to make neonatal nursing attractive as a career option.
B (High quality)
  • Develop evidence-based standards for medical and allied professional staffing. (21)
A (High quality)
  • Agree and implement a national or regional policy to ensure appropriate nurse staffing numbers. (15)
A (High quality)

Getting started

Initial steps
For parents and family
  • National parent representatives contribute to national consensus meetings on neonatal staffing.
For healthcare professionals
For neonatal unit
  • Develop and implement a unit guideline on nurse staffing requirements.
  • Inform health services and stakeholders about the importance of appropriate NICU staff numbers.
For hospital
  • Develop and educate nursing workforce.
  • Facilitate development of neonatal expertise by allied professionals.
For health service
  • Develop and implement a national guideline on nurse staffing requirements.
  • Organise expert stakeholder groups on a national level to reach consensus about nursing, medical and allied professional neonatal staffing requirements and their implementation.


  1. Patry C, Schindler M, Reinhard J, Hien S, Demirakca S, Böhler T, et al. A gap between Need and Reality: Neonatal Nursing Staff Requirements on a German Intensive Care Unit. Pediatr Rep. 2014 Feb 17;6(1):5186.
  2. Corchia C, Fanelli S, Gagliardi L, Bellù R, Zangrandi A, Persico A, et al. Work environment, volume of activity and staffing in neonatal intensive care units in Italy: results of the SONAR-nurse study. Ital J Pediatr. 2016 Apr 2;42:34.
  3. Pillay T, Nightingale P, Owen S, Kirby D, Spencer A. Neonatal nurse staffing and delivery of clinical care in the SSBC Newborn Network. Arch Dis Child Fetal Neonatal Ed. 2012 May;97(3):F174-178.
  4. Cimiotti JP, Haas J, Saiman L, Larson EL. Impact of staffing on bloodstream infections in the neonatal intensive care unit. Arch Pediatr Adolesc Med. 2006 Aug;160(8):832–6.
  5. Sink DW, Hope SAE, Hagadorn JI. Nurse:patient ratio and achievement of oxygen saturation goals in premature infants. Arch Dis Child Fetal Neonatal Ed. 2011 Mar;96(2):F93-98.
  6. Beltempo M, Lacroix G, Cabot M, Blais R, Piedboeuf B. Association of nursing overtime, nurse staffing and unit occupancy with medical incidents and outcomes of very preterm infants. J Perinatol Off J Calif Perinat Assoc. 2018 Feb;38(2):175–80.
  7. Leistner R, Thürnagel S, Schwab F, Piening B, Gastmeier P, Geffers C. The impact of staffing on central venous catheter-associated bloodstream infections in preterm neonates – results of nation-wide cohort study in Germany. Antimicrob Resist Infect Control. 2013 Apr 4;2(1):11.
  8. Hamilton KESC, Redshaw ME, Tarnow-Mordi W. Nurse staffing in relation to risk-adjusted mortality in neonatal care. Arch Dis Child Fetal Neonatal Ed. 2007 Mar;92(2):F99–103.
  9. Sherenian M, Profit J, Schmidt B, Suh S, Xiao R, Zupancic JAF, et al. Nurse-to-patient ratios and neonatal outcomes: a brief systematic review. Neonatology. 2013;104(3):179–83.
  10. Rogowski JA, Staiger D, Patrick T, Horbar J, Kenny M, Lake ET. Nurse staffing and NICU infection rates. JAMA Pediatr. 2013 May;167(5):444–50.
  11. Lake ET, Staiger D, Horbar J, Kenny MJ, Patrick T, Rogowski JA. Disparities in perinatal quality outcomes for very low birth weight infants in neonatal intensive care. Health Serv Res. 2015 Apr;50(2):374–97.
  12. The UK Neonatal Staffing Study Group. Relationship between probable nosocomial bacteraemia and organisational and structural factors in UK neonatal intensive care units. Qual Saf Health Care. 2005 Aug 1;14(4):264–9.
  13. Pessoa-Silva CL, Toscano CM, Moreira BM, Santos AL, Frota ACC, Solari CA, et al. Infection due to extended-spectrum beta-lactamase-producing Salmonella enterica subsp. enterica serotype infantis in a neonatal unit. J Pediatr. 2002 Sep;141(3):381–7.
  14. Watson SI, Arulampalam W, Petrou S, Marlow N, Morgan AS, Draper ES, et al. The effects of a one-to-one nurse-to-patient ratio on the mortality rate in neonatal intensive care: a retrospective, longitudinal, population-based study. Arch Dis Child Fetal Neonatal Ed. 2016 May;101(3):F195-200.
  15. British Paediatric Association (BPA). Service Standards for Hospitals Providing Neonatal Care (3rd edition) [Internet]. 2010. Available from:
  16. Gemeinsamer Bundesausschuss. Qualitätssicherungs-Richtlinie Früh- und Reifgeborene – QFR-RL [Internet]. 2018. Available from:
  17. The Royal College of Speech and Language Therapists (RCSLT). Neonatal care overview [Internet]. 2018. Available from:
  18. Royal College of Occupational Therapists. Occupational therapy in neonatal services and early intervention [Internet]. 2017. Available from:
  19. Association of Paediatric Chartered Physiotherapists (APCP). A Competence Framework and Evidence Based Practice Guidance for Physiotherapists Providing Respiratory Interventions for Preterm Infants in the United Kingdom [Internet]. 2014. Available from:
  20. Association of Paediatric Chartered Physiotherapists (APCP). A Competence Framework and Evidence Based Practice Guidance for the Physiotherapist Working in the Neonatal Intensive Care and Special Care Unit in the United Kingdom [Internet]. 2015. Available from:
  21. British Association of Perinatal Medicine (BAPM). Optimal Arrangements for Neonatal Intensive Care Units in the UK including guidance on their Medical Staffing. A Framework for Practice [Internet]. 2014. Available from:

November 2018 / 1st edition / next revision: 2023

Recommended citation

EFCNI, Poets CF, Helder O et al., European Standards of Care for Newborn Health: Nurse staffing in neonatal intensive care. 2018.

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